Axicabtagene ciloleucel (axi-cel; Yescarta) demonstrated significant and durable clinical benefit as well as a manageable safety profile in patients with relapsed or refractory indolent non-Hodgkin lymphoma.
Caron A. Jacobson, MD
An interim analysis of the phase II ZUMA-5 study indicated that axicabtagene ciloleucel (axi-cel; Yescarta) demonstrated significant and durable clinical benefit, with high rates of overall response rate (ORR) and complete response (CR) observed, as well as a manageable safety profile in patients with relapsed or refractory indolent non-Hodgkin lymphoma.1
These interim results, presented at the 2020 ASCO Virtual Scientific Meeting, suggest that axi-cel may be a promising approach for treating this patient population.
“Axi-cel yields high rates of response in indolent B-cell non-Hodgkin lymphoma,” Caron A. Jacobson, MD, of the Dana-Farber Cancer Institute, said during a presentation of the data. “Although longer follow-up is needed, these responses appear to be durable amongst follicular lymphoma patients.”s
Adults with relapsed or refractory follicular lymphoma (FL; grades 1-3a) and marginal zone lymphoma (MZL; nodal or extranodal) after ≥2 lines of therapy (including an anti-CD20 monoclonal antibody [mAb] with an alkylating agent), and an ECOG status of 0 or 1 were eligible for the study. Participants were leukapheresed and received conditioning chemotherapy followed by axi-cel infusion at 2 × 106 CAR T-cells/kg.
The primary endpoint of the study was objective response rate (ORR) by central review. Key secondary endpoints included duration of response (DOR), progression-free survival (PFS), overall survival (OS), safety, and blood levels of cytokines and CAR T-cells.
As of December 16, 2019, 140 patients (FL, n = 124; MZL, n = 16) had received axi-cel with a median follow-up of 15.3 months (range, 1.9-28.8). The median age of the participants was 63 years of age (range, 34-79), 49% of patients were male, 52% had stage IV disease, 51% had ≥ 3 FLIPI, and 49% had high tumor bulk (GELF). Moreover, patients had a median 3 prior lines of therapy, 66% progressed < 2 years after initial anti-CD20 mAb-containing therapy (POD24), and 73% were refractory to the last prior treatment.
Of the 96 patients evaluable for efficacy, the ORR was 93% (95% CI, 86-97) and the complete response (CR) rate was 80% (95% CI, 71-88). The median time to first response was 1 month (range, 0.8-3.1). More specifically, patients with FL (n = 80) had an ORR of 95%, with an 81% CR rate, and those with MZL (n = 16) had an ORR of 81%. With a 75% CR rate.
With a median follow-up of 15.3 months, the estimated DOR in all patients was 20.8 months, and 68% of patients with FL had an ongoing response as of the data cut-off. Moreover, the median PFS was 23.5 months (95% CI, 22.8 - NE) in all patients, and the median OS was not reached. However, the 12-months OS rate was 94.3% (95% CI, 86.8-97.6) for all patients.
All of the study participants were evaluable for safety, and 119 patients (85%) experienced grade ≥ 3 adverse events (AEs). The most commonly observed AEs were neutropenia (34%) and anemia (22%). Additionally, grade ≥ 3 cytokine release syndrome (CRS) and neurologic events (NEs) occurred in 8% and 17% of patients, respectively. There were only 2 grade 5 AEs, including multisystem organ failure in the context of CRS (related to axi-cel) and aortic dissection (unrelated to axi-cel).
“Given the long natural history of these diseases, safety is of paramount importance,” Jacobson said. “The safety profile was manageable and reversible, and appeared to be at least similar to that of axi-cel in aggressive lymphomas.”
The median time to peak of anti-CD19 CAR T-cell levels after axi-cel infusion was 8 days (range, 8 - 371). Furthermore, anti-CD19 CAR T-cells were detectable at 18 months in most patients with evaluable samples (13/15 [87%]).
Notably, in patients with FL, peak CAR T-cell expansion was associated with both grade ≥3 CRS (P = 0.0088) and neurologic events (P = 0.0076). In addition, peak serum analyses across multiple immune programs were associated with grade ≥ 3 CRS, grade ≥ 3 neurologic events, or both in patients with FL.
“This may have implications for the possibility of outpatient therapy for this disease in the future,” said Jacobson.
“Axi-cel appears to be a promising therapeutic approach for patients with relapsed and refractory indolent B-cell non-Hodgkin lymphoma.”
Axi-cel is currently approved by the FDA as a treatment for adult patients with relapsed or refractory large B-cell lymphoma based on findings from the phase II ZUMA-1 trial.2 The agent is indicated specifically following 2 prior therapies for those with diffuse large B-cell lymphoma (DLBCL), primary mediastinal large B-cell lymphoma (PMBCL), high grade B-cell lymphoma, and DLBCL transformed from follicular lymphoma (TFL).